As noted earlier, some survivors of mass trauma events may have both PTSD and prolonged grief. In such cases, these conditions can be treated concur- rently in the same program by giving self-exposure instructions relating to both conditions. In some sur- vivors particular distress cues may relate to both fear and grief reactions. For example, the location where the person experienced both the trauma and loss of close ones involves both types of distress cues. If, however, the survivorfinds it too difficult to work on both problems at the same time, they can tackle them in turn, starting with the one theyfind relatively easier to deal with and then turning to the other one. In some cases grief may need priority attention, as it may complicate treatment of PTSD by undermining moti- vation for treatment.
Step 1: identifying problem behaviors
Thefirst task in treatment is to identify grief-related avoidance and ritualistic behaviors that need to be Table 5.2 Concordance between self- and clinician-rated Behavior Checklist for Grief items
OC SE SP CC κ1
1. I feel like seeing his/her belongings out in the open. 2 71 88 85 0.50 2. I have difficulty looking at his/her pictures. 2 71 89 86 0.56 3. I avoid going to the place where he/she died. 2 78 93 89 0.72 4. I feel like seeing his/her pictures out in the open. 2 71 86 82 0.54 5. I feel like going to the places where we used to go together. 2 100 85 87 0.53
6. I have difficulty mentioning his/her name. 2 93 97 97 0.86
7. I avoid meeting his/her friends. 2 67 93 88 0.59
8. I have difficulty cooking/eating the meals that he/she used to like. 2 60 89 87 0.38
9. I avoid visiting his/her grave. 1 100 81 83 0.38
10. I have difficulty listening to the music he/she liked. 2 77 94 92 0.65
11. I feel like talking about him/her. 2 85 85 85 0.58
12. I have difficulty going to the places where we used to go together. 1 88 74 76 0.40
13. I avoid talking about him/her. 1 75 69 70 0.30
14. I have difficulty looking at his/her belongings. 2 74 95 91 0.68
15. I feel like visiting his/her grave. 2 78 81 80 0.56
OC = Optimum cut-off for self-rated scale items, SE = Sensitivity, SP = Specificity, CC = Correct Classification, κ = Measure of agreement. 1For all κ’s p < 0.001.
targeted during treatment. The BCG is often very useful for this purpose, as it includes the most com- mon grief behaviors associated with prolonged grief. When this instrument is used to elicit this informa- tion, it is important to bear in mind that the survivor may have other idiosyncratic forms of grief behaviors not covered by the questionnaire. This information could be captured by questions such as “Are there any other situations or activities that you avoid because they bring back distressing memories of your loved one?” or“Are there other things that you keep doing because they remind you of your loved one or because they keep his/her memory alive?”
Step 2: explaining treatment and its
rationale
Avoidance behaviors are treated with exposure to avoided cues in much the same way as in treatment of traumatic stress, whereas ritualistic behaviors require response prevention. The latter is a behavioral intervention used in treating obsessive rituals. Obsessive rituals (e.g. hand washing) are often trig- gered by cues (e.g. perceived dirt in hands) and serve to reduce the anxiety evoked by the cue. Preventing such rituals is thus a form of exposure to anxiety evoked by the cue. Response prevention has also been shown to be effective in treating prolonged grief (Boelen et al.,
2007). The treatment and its rationale could be explained as follows:
I can see from your initial assessment results that you still have substantial grief-related problems. Most
people recover from grief after 6–12 months to the
extent that they can resume reasonably normal functioning. If you look carefully, you will see that this is the case with most people who lost their loved ones during the earthquake. People usually respond to sudden loss with initial shock and disbelief but then they accept the loss and go through a period of grief. They eventually recover from grief and return to
a reasonably normal life. Some people, however,find
it difficult to accept the reality of their loss and
develop behaviors that may block natural grief proc- ess. Such behaviors are usually of two types. Some people avoid particular situations or activities that bring back distressing memories of the loss. For example, they may avoid visits to the cemetery, talk- ing about the lost one, looking at his/her pictures, or going to the location where s/he died. Others may repeatedly engage in certain activities to keep the
memory of the lost one alive at all times. For exam- ple, they may feel like talking about the lost one all the time, make frequent visits to his/her grave, keep his/her pictures all around the house, avoid giving away his/her clothes or other belongings, and keep his/her room exactly as it was before the event. Such behaviors are ritualistic in quality; one feels an urge to engage in them, which is often difficult to resist because this causes distress. Some people may dis-
play both types of grieving behaviors.
This treatment will help you change these behav- iors so that you can complete your grief. You can do this by not avoiding situations that bring back mem- ories of your loss and by not engaging in ritualistic behaviors. You may experience distress in the process but you will learn to tolerate and control it. This will help you get over your grief once and for all. Just think how this problem has taken control over your life. You will need to decide whether you want to live with this problem or do something about it. If you choose the latter option, you will need to conduct exercises to overcome your distress caused by the activities listed
in this questionnaire[Behavior Checklist for Grief ].
I will help you with this process. You are free to carry out your exercises at your own pace, tackling them gradually or one step at a time, if you like. Most people recover within 10 weeks, so you will need to complete your exercises within this time. We will then
choose onefinal homework task to mark the end of
your mourning and also of your treatment.
Some points concerning the treatment rationale deserve attention here. Prolonged grief is presented as a con- dition that occurs when the natural grief process is blocked by cognitive, behavioral and emotional avoid- ance of the painful reality of loss. The treatment is presented as a means of helping the person to come to terms with the reality of the loss so that s/he can com- plete the natural grief process. This is achieved by exposure to cues that evoke distress, grief, or other loss-related emotions. Thus, as in treatment of trau- matic stress, the intervention has a sharp behavioral focus and involves only live exposure. In Part 1 we discussed our observations pointing to the important role of risk taking and confronting feared situations in natural recovery from traumatic stress. Our observa- tions suggest that similar behavioral processes also play an important role in natural recovery from grief. It is worth briefly summarizing these observations and how they inspired certain aspects of our treatment of grief.
In many cultures the mourning process is associ- ated with a wide range of elaborate ceremonies and
rituals (Rosenblatt,2008) that appear to facilitate grief. For example, funeral ceremonies might serve to facil- itate acceptance of the loss by providing exposure to the sight of the loved one’s dead body, other people’s emotional reactions to the loss, and the burial process as further evidence of separation from the loved one. The sight of a dead body ingrained as the last visual memory of the loved one might be particularly impor- tant in this respect, which might perhaps explain why the relatives of the deceased are often actively encour- aged to see the body before burial (or why the body of the deceased is displayed in an open coffin during the funeral ceremony in some Christian cultures). Perhaps the most fascinating example we have come across in this respect concerns a tradition in some rural regions of Turkey, which involves the recruitment of a group of professional ‘mourners’ (termed ağıtçılar in Turkish). These are usually women with no relation to the deceased and their sole task is to display overt (and often exaggerated) grieving behaviors (e.g. crying loudly in a chorus, talking about how good the deceased was, how he or she will be missed, etc.) during the funeral ceremony and the days that follow. Such tradition appears to be designed to facilitate the grieving process in the bereaved. Following burial, visits by friends and neighbors paying their condolen- ces provide ample opportunities for talking about the deceased and crying. Furthermore, neighbors often take over domestic duties, such as cooking and clean- ing, for some days to relieve the bereaved of everyday work, which seems to ensure that grieving proceeds in a focused fashion uninterrupted by distractions. Social codes concerning the mourning process also appear to be geared towards facilitating grieving in the bereaved. Certain mourning behaviors (e.g. dressing in black) are deemed appropriate and expected, while others (e.g. appearing joyful, laughing, listening to music, singing, or engaging in other entertainment activities) are met with disapproval and discouraged. Finally, grieving is a time-limited process. Social codes encour- age mourning for a particular period of time, after which the bereaved is expected to resume normal life. In Turkey, for example, there are certain religious rituals that mark the end of the mourning period, which is often designated as the 40th day of the loss. There is even a descriptive term that refers to comple- tion of the mourning process (i.e.kırkı çıkmak) mean- ingcompletion of the 40th day.
These are merely a few examples which suggest that human response to loss has evolved throughout
history in ways to help them overcome the impact of loss. Many of the grief rituals and social processes that serve to facilitate resolution of grief are essentially behavioral in nature, as noted earlier. Accordingly, we have incorporated some of these processes into our treatment approach. This explains in part why the treat- ment is presented as a means of facilitating the grieving process and helping the person complete the natural grief cycle by confronting the distress associated with the loss. Furthermore, in an effort to recreate the time- limited nature of the natural grief process, a time frame is set in agreement with the client for the whole treat- ment process. A time frame implies that there is a beginning and an end to the grieving process and that the person is expected to discontinue mourning and resume normal life, once this process is completed. Defining a closure event for the grief process is often helpful in marking the end of the grief process. Such closure is best defined by an exposure task that is most difficult to achieve and / or one that is with most sym- bolic significance for the person. This could be, for example, removing the deceased person’s belongings from sight or giving them away. Similarly, afinal cem- etery visit could be arranged, together with other close ones and in a ceremonial fashion, to mark the end of the grieving process.
A potential problem in engaging the client in the idea of treatment deserves mention here. Some peo- ple regard their grief process as natural, no matter how prolonged and disabling their grief might be. We have seen survivors with such intense grief (usually associated with child loss) that they simply did not care about their own disaster-related problems, psy- chological or other, or the adverse impact of grief on their life functioning. Such survivors were reluctant to accept treatment for their grief problems. We often tried to negotiate a deal with such cases, asking them to give the treatment a try (e.g. conducting one or two exposure tasks) and then decide whether or not they want to continue with treatment. This strategy worked in most cases, as they found the early impact of treatment sufficiently rewarding to continue with treatment.
Step 3: defining exposure tasks and giving
self-exposure instructions
Once an agreement is reached on the need for treat- ment, the next step is to define the exposure tasks and provide self-exposure instructions. The BCG would be
useful in defining the treatment tasks. As a general rule, behaviors endorsed as ‘fairly’ or ‘very much’ need attention in treatment (though the item cut-off points indicated inTable 5.2could also be taken into account). It is best to make a list of the endorsed behaviors and the exposure tasks targeting them. The BCG items define the following tasks:
Tasks relating to avoidance behaviors
* Looking at loved one’s pictures
* Looking at loved one’s belongings
* Cooking/eating the meals that loved one used to
like
* Going to the place where loved one died
* Meeting with loved one’s friends
* Talking about loved one
* Visiting loved one’s grave
* Listening to the music that loved one liked
* Going to the places where the survivor used to go
together with loved one
Tasks relating to ritualistic behaviors
* Removing loved one’s pictures from sight or stop
looking at them
* Removing loved one’s belongings from sight or
stop looking at them
* Not going to the places where the survivor used to
go together with loved one
* Not talking about loved one
* Not visiting loved one’s grave
The list is likely to include both avoidance and ritual- istic behaviors, although some people may display more behaviors of one type than the other. Note once again that the BCG is not an exhaustive list of grief behaviors. It is thus important to make sure that any problem behaviors not included in the scale are listed under the‘Others’ item and included in the list of exposure tasks. Once the list of problem behaviors is drawn up, the survivor is told that the aim in treatment is to change these behaviors by (a) not avoiding the activities that cause distress and (b) not engaging in ritualistic behaviors that maintain grief reactions. The following explanation about the treatment process is often useful:
You can start working on your tasks in any order you like. If you like, you can start with the easier ones and,
when you feel you can tolerate distress better, move
on to more difficult ones. Look at your task list and
decide which ones are the easiest and which ones are more difficult to achieve. You can also break a diffi- cult task into easier steps. For example, if you are keeping your lost one’s pictures or belongings out in the open so that you can see them all the time, you can begin your task by removing these items one by one, instead of all of them at once. Or you can remove them in a particular order, starting with the ‘easier-to-remove’ items first. Similarly, you can give away his/her belongings one by one, starting with
the easiest itemsfirst. If you feel you cannot stop
cemetery visits at once, you can reduce their fre- quency gradually. You may experience a certain amount of distress in achieving each task but this is natural and not undesirable. Remember always that this will help you to learn to tolerate the distress caused by your loss so that you can complete your grief in a natural fashion. The distress you experience in executing these tasks may include feelings of anger, blame, or guilt. Executing these tasks may also make you feel guilty because they may come across to you as giving up on your lost one or as betraying his/her memory. This is natural and most grieving people have such thoughts and feelings. You will recover from such emotions as your treat- ment progresses and you will most likely feel different about the issues that bring about these emotions.
Note also that the aim of treatment is not to deprive you of all memory of your lost one forever. It is normal to keep some pictures of the lost one in the living room or make cemetery visits from time to time, as most people do. These tasks are simply designed to help you come to terms with your loss. When the treatment is over and you are no longer distressed by the thought of removing them from your sight, you can put back some of the pictures in your living room. Bear in mind that there is a time frame for this treatment. It is designed for a maximum of 10 weeks, as most people are able to complete their tasks within this period. Plan your treatment accordingly. Consider the number of tasks you have. If you have 10, for example, this means you can complete all tasks in 10 weeks by working on one task each week. You can, however, work on as many tasks as you want each week and complete the treatment even
earlier. This is entirely up to you.
Subsequent sessions
Subsequent treatment sessions are conducted in much the same way as in treatment of traumatic stress. The sessions involve an initial assessment
using the BCG, a review of progress in the last week, verbal praise for any progress achieved, troubleshoot- ing for problems encountered, and defining new exposure tasks. As the exposure tasks can increase the person’s distress levels in the early phase of treat- ment, strong encouragement and emotional support might be needed during this time to avoid premature termination of treatment.
In some cases a therapist-assisted exposure ses- sion might be necessary to help the survivor with some difficult tasks. Visiting the site where the loved one died, for example, is a difficult task for most people, particularly when the person has witnessed the death of the lost one. The survivor may break into tears and start talking about the trauma expe- rience during the session. This is often an emotion- ally taxing experience for both the survivor and the therapist. During the session the therapist needs to maintain a certain emotional distance from the event and help the survivor, if necessary, to relive the experience by getting them to talk about the deceased and the events that led to his/her death. Getting the person to relate the story several times often helps. Such sessions are often conducive to a sense of great relief on the part of the survivor